Assessment and Treatment of Addictive Behaviors Carl W. Lejuez, PhD

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Assessment and Treatment of Addictive
BehaviorsCarl W. Lejuez, PhD

• Lecture 4

Assessment of Gambling and eating disorders
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Eating Disorders Overview

• Eating controlled by factors including appetite,
  food, family, peer, and cultural practices, and
  attempts at voluntary control
• Dieting to a body weight leaner than needed for
  health is highly promoted by current fashion
  trends, sales campaigns for special foods, and in
  some activities and professions
• Eating disorders involve serious disturbances in
  eating behavior, such as extreme and unhealthy
  reduction of food intake or severe overeating, as
  well as feelings of distress or extreme concern
  about body shape or weight.
• Eating disorders are not due to a failure of will
  or behavior rather, they are real, treatable
  medical illnesses in which maladaptive patterns
  of eating take on a life of their own.
• Main types are anorexia nervosa and bulimia
  nervosa

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Eating Disorders Overview 2

• Several family and twin studies are suggestive of
  a high heritability of anorexia and bulimia and
  researchers are searching for genes that confer
  susceptibility to these disorders
• Scientists suspect that multiple genes may
  interact with environmental and other factors to
  increase the risk of developing these illnesses.
  Identification of susceptibility genes will
  permit the development of improved treatments for
  eating disorders

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Eating Disorders Prevalence

• Frequently develop during adolescence or early
  adulthood, but can occur during childhood or
  later in adulthood
• Approximately 1 of adolescent girls develop
  anorexia nervosa.
• Approximately 2-3 of young women develop bulimia
  nervosa.
• Two percent of adults suffer from binge eating
  disorder.
• 90 of those with eating disorders are adolescent
  young women.
• Bulimia is as high as 15 in college aged women.
• Although the common perception is that eating
  disorders are most prevalent among white, upper
  middle class young women, recent research
  indicates that of those who suffer from eating
  disorders
• 1 in 5 are poor
• 1 in 4 are non-white
• teenagers with asthma, attention deficit
  disorder, diabetes, and other chronic illnesses
  are reported to experience eating disorders 2 to
  4 times more often

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Eating Disorders and Males

• 5-10 of eating disorders occur among males
• Men more frequently use excessive and obsessive
  exercise and body-building prior to and during
  their eating disorder
• Issues relating to sexuality and gender identity
  are sometimes associated with male eating
  disorders and there appears to be a higher rate
  of eating disorders among gay males
• Men may be less likely to seek treatment for an
  eating disorder because of the social stigma of
  have a problem that has generally been perceived
  as a "woman's problem."
• The signs, symptoms and treatment needs of eating
  disorders in males are similar to those of women

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Risk factors

• Biological
• Genetic predisposition
• Hypothalamic dysregulation/dysfunction
• Serotonin deficits

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Other Risk Factors

• Family/environment
• Abuse
• overcontrolling
• Personality
• Perfectionism
• Compliance
• Inhibition
• Neuroticism/anxiety
• Low self-esteem
• Depression
• Poor introceptive awareness

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Anorexia Nervosa
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Anorexia Prevalence

• Onset is usually in adolescence and affects
  females 101 over males. Prevalence in young
  women is up to 1
• Some will have episodes of binge eating or
  purging. Anorexia is a life-threatening disorder,
  with mortality over 10
• An estimated 0.5 to 3.7 percent of females suffer
  from anorexia nervosa in their lifetime

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Anorexia General Features

• Intense fear of gaining weight
• Belief that they are fat, but actually very thin
• Restriction of calories
• Avoids social situations where s/he may have to
  eat in front of others
• Unusual eating habits or rituals
• Obsessive or compulsive exercise
• Hyperactivity or fatigue
• Isolation from friends and family

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Anorexia DiagnosisSymptom 1

• Refusal to maintain body weight at or above a
  minimally normal weight for age and height (85)

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Anorexia DiagnosisSymptom 2

• Intense fear of gaining weight, even though
  underweight

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Anorexia DiagnosisSymptom 3

• Disturbance in the way in which one's body weight
  or shape is experienced, undue influence of body
  weight or shape on self-evaluation, denial of
  seriousness of current low body weight.

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Anorexia DiagnosisSymptom 4

• In postmenarcheal females, amenorrhea, i.e., the
  absence of at least three consecutive menstrual
  cycles

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Anorexia DiagnosisSubtypes

• Restricting type
• During the current episode of anorexia nervosa,
  the person has not regularly engaged in
  binge-eating or purging behavior (i.e.,
  self-induced vomiting or the misuse of laxatives,
  diuretics or enemas)
• Binge-eating/purging type
• During the current episode of anorexia nervosa,
  the person has regularly engaged in binge-eating
  or purging behavior (i.e., self-induced vomiting
  or the misuse of laxatives, diuretics or enemas).

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Anorexia Complications

• Dehydration
• Changes in metabolism reduced energy
• Dry skin/sallow complexion
• Growth of fine hair over body and face
• Purple nail beds and cold extremities
• Dizziness, low blood pressure, fainting
• Anemia
• Tooth decay
• Osteoporosis
• Gastrointestinal Complications
• Hypoglycemia/hypothermia
• Kidney/pancreas failure
• Endocrine dysregulation
• Cardiac problems/ heart failure

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Bulimia Nervosa
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Bulimia Prevalence

• An estimated 1.1 percent to 4.2 percent of
  females have bulimia nervosa in their lifetime

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Bulimia General Features

• Fear of being fat
• Eats in secret
• Uses bathroom immediately after meals
• Purges foods in many different ways
• Hoards food
• Mood swings
• Abuse of alcohol or other substances
• Over-exercising
• Isolation from friends and family

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Bulimia DiagnosisSymptom 1

• Recurrent episodes of binge eating. An
  episode of binge eating is characterized by both
  of the following 
• eating, in a discrete period of time (e.g.,
  within any 2-hour period), an amount of food that
  is definitely larger than most people would eat
  during a similar period of time and under similar
  circumstances
• a sense of lack of control over eating during the
  episode (e.g., a feeling that one cannot stop
  eating or control what or how much one is eating) 

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Bulimia DiagnosisSymptom 2

• Recurrent inappropriate compensatory behavior in
  order to prevent weight gain, such as
  self-induced vomiting misuse of laxatives,
  diuretics, enemas, or other medications fasting
  or excessive exercise. 

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Bulimia DiagnosisSymptom 3

• The binge eating and inappropriate compensatory
  behaviors both occur, on average, at least twice
  a week for 3 months. 

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Bulimia DiagnosisSymptom 4

• Self-evaluation is unduly influenced by body
  shape and weight. 

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Bulimia DiagnosisSymptom 5

• The disturbance does not occur exclusively during
  episodes of Anorexia Nervosa. 

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Bulimia DiagnosisSpecific Type

• Purging Type during the current episode of
  Bulimia Nervosa, the person has regularly engaged
  in self-induced vomiting or the misuse of
  laxatives, diuretics, or enemas
• Nonpurging Type during the current episode of
  Bulimia Nervosa, the person has used other
  inappropriate compensatory behaviors, such as
  fasting or excessive exercise, but has not
  regularly engaged in self-induced vomiting or the
  misuse of laxatives, diuretics, or enemas

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Bulimia Complications

• Electrolyte abnormalities
• Dehydration/kidney disease
• Reduction of blood calcium
• Tooth decay/enamel erosion
• Digestive and intestinal problems
• Muscle spasms and headaches
• Colon abnormalities
• Abnormal thyroid hormone and growth
• Bleeding and infection of the throat
• Enlargement of lymph or salivary glands
• Pancreatic disease

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Binge Eating Disorder Overview

• A newly recognized eating disorder characterized
  by frequent episodes of uncontrolled overeating.
  
• The prevalence of binge eating disorder in the
  general population is still being determined.
  Researchers estimate that approximately 25 of
  obese individuals suffer from frequent episodes
  of binge eating (Fairburn, 1998).
• Binge eating disorder affects women slightly more
  often than men--estimates indicate that about 60
  of people struggling with binge eating disorder
  are female, 40 are male (NIH, 1993).
• People who struggle with binge eating disorder
  can be of normal or heavier than average weight.
• Many people who suffer from binge eating disorder
  have a history of depression (NIH, 1993).
• People struggling with binge eating disorder
  often express distress, shame, and guilt over
  their eating behaviors.

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Binge Eating Disorder Diagnosis

• Frequent episodes of eating large quantities of
  food in short periods of time often secretly,
  without regard to feelings of hunger or
  fullness.
• Frequently feeling of out of control during
  binges
• Eating large quantities of food rapidly, w/o
  tasting
• Eating alone
• Feelings of shame, disgust, or guilt after a
  binge
• Binge eating disorder often results in some of
  the health risks associated with clinical obesity

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Assessment Measures

• EDE Eating Disorder Evaluation
• Structured Clinical Interview
• EAT Eating Attitudes Test (Garner)
• EDI Eating Disorders Inventory (Garner)
• Comprehensive eating disorders scale
• BULIT- Bulimia Test (Thalen)
• Assesses all aspects of bulimia and some anorexia
• BES- Binge Eating Scale (Gormally)
• Primarily for binge eating in obese individuals
• COEDS- College Oriented Eating Disorders Scale
  (Nowak)

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• Gambling Assessment

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Gambling Overview

• Problem gambling is
• gambling behavior which causes disruptions in any
  major area of life psychological, physical,
  social or vocational
• The term "Problem Gambling" includes, but is not
  limited to, the condition known as
  "Pathological", or "Compulsive" Gambling, a
  progressive addiction characterized by increasing
  preoccupation with gambling, a need to bet more
  money more frequently, restlessness or
  irritability when attempting to stop, "chasing"
  losses, and loss of control manifested by
  continuation of the gambling behavior in spite of
  mounting, serious, negative consequences.

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Gambling Stats

• Some form of gambling legal in every state but
  Utah Hawaii
• In 1992, 54 of Americans purchased a lottery
  ticket, and 25 of them were in a weekly habit.
• 24 states have casinos, and 37 have state
  lotteries
• In 1996, 2.5 billion dollars was bet legally in
  the U.S. an estimated 90 billion illegally.
• Of all college athletes, 25 of them bet, 4 on
  own games
• The odds of winning the average lottery 1 in 5
  million
• The odds of getting struck by lightning 1 in
  600,000
• Vegas expects 30,300,000 visitors this year.

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Gambling Stats

• Nevada Casinos won 7.52 billion dollars in
  fiscal 1996 That's 5.2 higher than 1995
• Two out of three casino visitors in Mississippi
  are out of staters
• In 1993, 92 million people visited casinos.
• Legal Gambling revenues 30 billion dollars a
  year, more than movies, books, music, and arcades
  combined
• 95 of all people live within 4 hrs of a casino
• In 1988, this is the amount spent on lottery
  tickets per person. New York- 91.17
  Pennsylvania- 121.48 New Jersey- 152.07
  Conneticut- 158.53 Massachusets- 234.92
• On average, gamblers are 47 years old, and their
  hoseholds visit casinos 3.9 times a year, and
  wager 25-100 per visit

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Gambling Prevalence

• Gambling exposure/access greatly increased
• Estimates suggest between 1 and 1.5 percent of
  the population could be classified as
  pathological gamblers (DSM-IV)
• Another 3 have some gambling problems
• Pathological gambling may be as high as 5 in
  adolescents and college students
• Higher rates and earlier onset in males

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Pathological Gambling Diagnosis DSM-IV

• Placed within the impulse controls disorders
  section of the DSM
• Persistent and maladaptive gambling behavior
  indicated by 5 or more of the characteristics
  mentioned on the following slides

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Pathological Gambling Diagnosis DSM-IV (1-5)

• Preoccupied with gambling
• Needs to gamble with increasing amounts of money
  in order to achieve the desired excitement
• Has repeated unsuccessful efforts to control, cut
  back, or stop gambling
• Restless or irritable when attempting to cut down
  or stop gambling
• Gambles as a way of escaping from problems or of
  relieving a dysphoric mood (ex. helplessness,
  guilt, anxiety, depression)

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Pathological Gambling Diagnosis DSM-IV (6-10)

• After losing money gambling, often returns
  another day to get even ("chasing" one's losses)
• Lies to family members, therapist, or others to
  conceal the extent of involvement with gambling
• Has committed illegal acts such as forgery,
  fraud, theft, or embezzlement to finance gambling
• Has jeopardized or lost a significant
  relationship, job, or educational or career
  opportunity because of gambling
• Relies on others to provide money to relieve a
  desperate financial situation caused by gambling

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Gambling Assessments

• Gamblers Anonymous 20 Questions (GA-20) A list
  of 20 questions devised by Gamblers Anonymous to
  help individuals decide if they have a gambling
  problem. According to GA, most people with
  gambling problems will answer "yes" to at least
  seven of the 20 questions. The questions have not
  been scientifically validated.

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Gambling Assessments

• South Oaks Gambling Screen (SOGS) A series of
  questions used to determine the presence of a
  gambling problem. Developed by Henry Lesieur and
  Sheila Blume of the South Oaks Psychiatric
  Hospital, the instrument consists of 20 items,
  with a score of five or higher considered
  evidence of pathological gambling. The South Oaks
  Gambling Screen has been the most widely used
  instrument in assessing the prevalence of
  pathological gambling among the general public,
  though it has not been specifically validated for
  that use.
• SOGS-RA A modified version of the South Oaks
  Gambling Screen used in assessing adolescents.

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Gambling Assessments

• NORC DSM Screen for Gambling Problems (NODS) A
  structured interview used to determine the
  prevalence of problem gambling in a population
• The NODS consists of 17 questions designed to
  reflect the DSM-IV criteria and was devised by
  the National Opinion Research Center (NORC) for
  the 1999 National Survey of Gambling Behavior
• The NODS classifies respondents as non-gamblers,
  low-risk (gamblers with no adverse effects),
  at-risk (gamblers meeting one or two of the DSM
  criteria), problem (gamblers meeting three or
  four criteria), and pathological (gamblers
  meeting five or more criteria)

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Gambling Terms

• Bad beat A run of bad luck.
• Bailout Money given to a gambler that allows
  them to pay debts without suffering adverse
  consequences.
• Chasing Attempt to make up previous losses
  through additional gambling, a common symptom of
  a pathological gambler. It involves larger bets
  and/or greater risks.
• Controlled gambling A theory of treatment for
  pathological gambling in which the patient is
  allowed to gamble on a limited basis. Controlled
  gambling currently has few adherents in North
  America but is somewhat more popular overseas
• Gam-Anon A fellowship for the families of
  pathological gamblers with chapters throughout
  North America.

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Gambling Types

• Disordered gambling A term coined by Howard
  Shaffer, Matthew Hall, and Joni Vander Bilt in
  1997 to encompass the range of pathological,
  problem and excessive gambling.
• level 1 no gambling problems
• level 2 problems that do not meet the criteria
  for pathological gambling
• level 3 pathological gamblers.

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Gambling Types

• Social gambler
• Gamblers who exhibit few or none of the
  difficulties associated with problem or
  pathological gambling
• Social gamblers will gamble for entertainment,
  typically will not risk more than they can
  afford, often gamble with friends, chase losses
  briefly, gamble for limited periods of time
• Not preoccupied with gambling

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Gambling Types

• Professional gambler
• One who gambles as way to make part/all of living
• Often confused with pathological gamblers,
  professional gambling is characterized by limited
  risks, discipline, and restraint, items all
  lacking in the pathological gambler.
• Professional gamblers wager on games with skill
  elements rather than games of chance, and wait to
  bet until the odds are more in their favor.
• Can lose control and exhibit chasing behavior, at
  which time they become problem or pathological